This act shall be known and may be cited as the “Out-of-Network Ambulance Service Provider Act”.

As used in the Out-of-Network Ambulance Service Provider Act:

1. “Ambulance service provider” means an ambulance service as defined by Section 1–2503 of Title 63 of the Oklahoma Statutes except that, for the purposes of this act, the term shall be limited to an ambulance service provider that provides ground transportation services;

2. “Covered ambulance services” means those ground ambulance services which an enrollee is entitled to receive under the terms of a health care benefit plan;

3. “Enrollee” means a person who is entitled to receive covered ambulance services under the terms of a health care benefit plan;

4. “Health care benefit plan” means a plan, policy, contract, certificate, agreement, or other evidence of coverage for health care services offered, issued, renewed, or extended in this state by a health care insurer, or government-sponsored self-insured plans. Health care benefit plan does not include any health plan offered by a contracted entity as defined in Section 4002.2 of Title 56 of the Oklahoma Statutes that provides coverage to members of the state Medicaid program;

5. “Health care insurer” means an entity that is subject to state insurance regulation and provides coverage for health benefits in this state and includes the following:

6. “Out-of-network” means a provider that does not contract with the health care insurer of the enrollee receiving the covered ambulance services; and

7. “Clean claim” means a claim that has no defect of impropriety, including any lack of required substantiating documentation or particular circumstances requiring special treatment that prevents timely payment from being made on the claim.

A. The minimum allowable reimbursement rate under any health care benefit plan issued by a health care insurer to an out-of-network ambulance service provider for providing covered ambulance services shall be at the rates set or approved, whether in contract or ordinance, by a local governmental entity in the jurisdiction in which the covered ambulance services originate.

B. In the absence of the rates as provided in subsection A of this section, the rate shall be the lesser of:

1. Three hundred twenty-five percent (325%) of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services under Title XVIII of the Social Security Act for the same services provided in the same geographic area; or

2. The ambulance service provider's billed charges.

C. Payment made in compliance with this section shall be considered payment in full for the covered ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing feature amounts required to be paid by the enrollee. An ambulance service provider is prohibited from billing the enrollee for any additional amounts for the paid covered ambulance services in excess of what the health care insurer pays.

D. All copayments, coinsurance, deductible, and other cost-sharing feature amounts provided by subsection A of this section shall not exceed the in-network copayment, coinsurance, deductible, and other cost-sharing features for the covered ambulance services received by the enrollee.

E. In administering and paying claims, a health care insurer shall comply with Section 1219 of Title 36 of the Oklahoma Statutes.